Page 4 - Cover Letter and Evaluation for Debbie Workman

Medicare Advantage plans

Advantage plans are managed-care plans – primarily HMO’s and PPO’s. Before enrolling in an
Advantage plan, you should verify with the providers that you want to see that they are in the
plan’s network (occasionally the online directories that we use are out of date).

Usually we try to include at least one PPO plan in evaluations, but in Spokane County there do
not seem to be any PPO plans that match your needs. All of them have relatively high costs for
the Rx drugs that you take and in some cases sizable health premiums. That leaves only
Advantage HMO plans, which as you may know have restrictive rules. In HMOs, except in
emergencies, you will probably not be covered when you go to a non-network provider. And
you will likely need a referral from your primary care doctor before you can see a specialist. In
exchange for accepting these restrictions, you can often save money in an HMO, particularly if
you see only network providers.

You indicated in your questionnaire that you may be interested in getting your health care from
the Providence Medical Group. It is listed as a network provider in both Advantage plans
compared in your evaluation, as shown in Appendices B2 and C1. But you should verify that
prior to enrolling. Also, it’s possible that even though the Providence Medical Group is in an
Advantage plan’s network, not all its doctors are. In any case, it’s wise to verify that you will be
covered when you go to the providers you want to see.

Here are summaries of the two Advantage plans compared in your evaluation.

1) Humana Gold Plus HMO Plan. This plan has many good features that include low costs
for your prescription drugs as well as zero premiums and no deductible for health
coverage. It has a large network of more than 3,500 providers, including the Providence
Medical Group, along with an above-average four-star quality rating from Medicare (five
stars is best).

Probably this plan’s weakest feature is its $5,900 out-of-pocket limit, which is high for
an HMO. Also, co-payments for an office visit to a specialist are $50, which is relatively
high. In most cases, co-payments are $10 for office visits to your primary care doctor
(recommended preventive tests are 100% covered and do not require co-payments).

2) AARP Medicare Complete Plan 1 HMO Plan. This plan also has zero premiums for
health coverage, no health plan deductible, and like the Humana plan a Medicare-
quality rating of four stars. Co-payments for office visits to specialists are $45 and $10
for office visits to your primary care doctor.

This plan has a network of more than 1,000 providers, which is average for an HMO in
an urban area. Its $5,500 out-of-pocket limit is $400 lower than that of the Humana
Gold Plus HMO Plan.

4